SW: Final Project

O R I G I N A L P A P E R

Trauma-Informed Social Work Practice: Practice Considerations and Challenges

Carolyn Knight

Published online: 19 February 2014

� Springer Science+Business Media New York 2014

Abstract Adult survivors of childhood trauma are an

especially challenging group of clients, given the long-term

effects of the victimization and the present day difficulties

these individuals face. In this article, trauma-informed

practice is explained, incorporating the most recent theo-

retical and empirical literature. The purpose is to educate

and provide support to clinicians who encounter survivors

of childhood trauma in a range of settings that are partic-

ularly likely to serve this population like addictions, mental

health, forensics/corrections, and child welfare. The social

worker neither ignores nor dwells exclusively on the past

trauma. Rather, trauma-informed practitioners are sensitive

to the ways in which the client’s current difficulties can be

understood in the context of the past trauma. Further, they

validate and normalize the client’s experiences. Trauma-

informed practice requires the practitioner to understand

how the working alliance, itself, can be used to address the

long-term effects of the trauma. Emphasis is placed on

helping survivors understand how their past influences the

present and on empowering them to manage their present

lives more effectively, using core skills of social work

practice.

Keywords Childhood trauma � Sexual abuse � Clinical intervention � Indirect trauma � Child maltreatment � Adult survivors

Introduction

Adult survivors of childhood trauma account for a majority

of individuals seeking or required to seek clinical services

(Bride 2004; Harper et al. 2008; Probst et al. 2011). Much

has been written about working with this population, but

most of this literature assumes that the past trauma will be

the primary focus of the professional intervention. How-

ever, many practitioners encounter trauma survivors in

settings like addictions, mental health, child welfare, and

corrections/forensics, where these individuals are particu-

larly likely to require or seek out services (Macy 2007;

Pence 2011). The focus in these practice contexts typically

is on the present-day difficulties with which the survivor is

struggling, rather than the underlying past trauma.

Clinicians in these settings often feel ill-equipped to be

helpful to survivors, mistakenly assuming they lack the

required knowledge and expertise (Binder and McNeil

2007; Fusco and Platania 2011). Survivors’ sense of

urgency regarding their current problems-in-living, cou-

pled with the limited role that many practitioners play in

meeting their clients’ needs, often results in the history of

past trauma being overlooked, along with the impact that

this may have on current functioning (Chemtob et al. 2011;

Pence 2011; McGowan 2013). This is frustrating to clini-

cians and survivors alike. In fact, practitioners who do not

attend to survivors’ past, and the relationship it plays in the

present, undermine their ability to deal with the underlying

trauma and the present-day challenges that brought them

into treatment in the first place (Harper et al. 2008; Twaite

and Rodriguez-Srednicki 2004).

This article addresses a gap in the trauma literature by

focusing on the many instances in which a survivor of

trauma seeks out or is required to seek out treatment, not

for the past trauma, but for current problems in living. It

C. Knight (&) School of Social Work, University of Maryland Baltimore

County, 1000 Hilltop Circle, Baltimore, MD 21250, USA

e-mail: [email protected]

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Clin Soc Work J (2015) 43:25–37

DOI 10.1007/s10615-014-0481-6

begins with an overview of current theory and research

regarding the nature and long-term consequences of

childhood trauma. This is followed by an examination and

discussion of what is referred to as trauma-informed

practice (Brown et al. 2012; Layne et al. 2011), incorpo-

rating the most recent theoretical and empirical literature.

Case examples illustrate core concepts. The case material

reflects composites of actual client situations; all identify-

ing information has been changed to protect clients and

practitioners.

Nature of Childhood Trauma

The earliest definitions of childhood trauma emphasized the

event, itself and the traumatizing effects it had on its victims.

More recent conceptualizations recognize that the same

event will be experienced differently, based upon a range of

variables including cultural context and social and psycho-

logical factors unique to the individual (Elliott and Urquiza

2006). Williams and Sommer (2002) argue that, ‘‘Trauma is

in the eyes of the beholder…’’ (p. xix). More recent con- ceptualizations of trauma also have moved away from a sole

focus on pathology and dysfunction. Researchers point to the

existence of ‘‘adversarial’’ or ‘‘posttraumatic growth’’

(Bonnanno 2004; Linley and Joseph 2004); survivors’ sense

of self-efficacy, their ability to cope with challenging events

in the future, and their spirituality can be enhanced as a result

of exposure to trauma.

Childhood trauma, particularly in the form of interper-

sonal victimization like sexual and physical abuse, has

been found to be associated with a host of difficulties

ranging from emotional and psychological reactions such

as depression, low self-esteem, and suicidal ideation;

physical problems like chronic pain; psychiatric problems

such as anxiety/panic, borderline, post-traumatic stress, and

dissociative identity disorders; and behavioral problems

including substance abuse, eating disorders, domestic vio-

lence, and self-injury (Farrugia et al. 2011; Kuo et al. 2011;

Shafer and Fisher 2011; Spitzer et al. 2006).

Childhood trauma also distorts survivors’ thinking about

their social world and leads to social isolation and prob-

lems with attachment (Waldinger et al. 2006). Survivors

are likely to develop core beliefs about self and others that

are characterized by low self-esteem and feelings of

worthlessness, powerlessness, and vulnerability, as well as

mistrust of others (McCann and Pearlman 1990). Child-

hood trauma robs its victims of a stable sense of self. This

results in a lack of the ‘‘self-capacities’’ (McCann and

Pearlman 1990), that allow individuals to ‘‘maintain a

consistent sense of identity and positive self-esteem’’ (p.

21). These self-capacities reflect basic coping mechanisms

like the ability to: soothe and comfort oneself when

distressed; be alone and comfortable with oneself; experi-

ence a full range of affective reactions without being

overwhelmed by or denying them; regulate emotions; and

accept criticism and negative feedback.

There also is increasing evidence to suggest that expo-

sure to trauma in childhood leads to neurobiological

changes in the developing brain. These changes appear to

be more or less permanent and reinforce the previously

identified social, emotional, and behavioral consequences

of the abuse (Coates 2010; Delima and Vimpani 2011;

Rothschild 2003; Teicher et al. 2003).

Trauma-Informed Practice: Definition

When clinicians work in settings that are likely to serve

adults with histories of childhood trauma, it is important

that they entertain the possibility that the client could have

such a history, regardless of whether or not the client

presents her or himself as a survivor. Trauma informed

practice doesn’t mean that the practitioner assumes the

client is a survivor. It also doesn’t mean that the focus of

the intervention will be on the past trauma.

Rather, the practitioner is sensitive to this possibility and to

the ways in which the client’s current problems can be

understood in the context of past victimization. The worker

also recognizes the potential implications that being a survivor

have for the client’s willingness and ability to enter into a

working alliance; evidence suggests this may be especially

challenging for survivors, given core beliefs characterized by

hostility towards others, and their difficulties forming positive

attachments (Monahan and Forgash 2000; Stovall-McClough

and Cloitre 2006). ‘‘The development of the therapeutic alli-

ance…is often a daunting challenge with an interpersonally victimized [client]. The [worker] may be perceived as a stand-

in for other untrustworthy and abusive authority figures to be

feared, challenged, tested, distanced from, raged against,

sexualized, etc.’’ (Courtois 2001, p. 481).

Unlike trauma-centered intervention, where the under-

lying trauma is the primary focus of the intervention,

trauma informed practice helps survivors ‘‘develop their

capacities for managing distress and for engaging in more

effective daily functioning’’ (Gold 2001, p. 60). The effects

of the past childhood trauma aren’t ignored, but ‘‘extensive

and detailed immersion in [traumatic] material itself is not

encouraged, because…this tactic is…destabilizing and counter-productive’’ (Gold 2001, p. 60).

Importance of the Professional Relationship

Trauma-informed practice recognizes that the working

alliance can provide a corrective emotional experience for

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survivors (Banks 2006). The relationship can challenge

distortions in thinking about self and others, and it can be a

means through which self-capacities can be developed

(McCann and Pearlman 1990). For example, when practi-

tioners understand and anticipate ‘‘traumatic transference’’

(Spiegel 1986), whereby they represent those who have

exploited the survivor, they can assist the client in con-

fronting directly fear and mistrust of others (Dalenberg

2004; Horvath 2000). Further, the worker’s affective

reactions to the survivor and her or his story affirm and

give voice to the client’s own reactions (Courtois 2001).

The therapeutic potential of the relationship depends

upon workers being knowledgeable about childhood

trauma and its relationship to the client’s current difficul-

ties. The worker acknowledges the trauma directly and

responds empathically, but does so in a way that is con-

sistent with her or his professional role (Glover et al. 2010;

Karatzias et al. 2012). The results of several studies reveal

that survivors of trauma are likely to have been in treat-

ment multiple times and to report having experiences with

professionals that were not helpful and often counterpro-

ductive (Beutler and Hill 1992; Palmer et al. 2001;

Schachter et al. 2003). Specifically, survivors reported as

unhelpful clinicians who: avoided addressing the trauma at

all, asked for too much detail and encouraged expression of

feelings when it wasn’t appropriate, and minimized the

significance of the trauma in the client’s current life.

The therapeutic potential of the working alliance also

depends upon the worker adhering to professional bound-

aries to enhance survivors’ self-capacities. Survivors’ sense

of urgency can lead the worker to engage in practice

activities that are inconsistent with her or his role in

agency-based or private practice. It also can lead the

worker to extend her or himself in ways that move the

relationship away from a professional one into a realm that

is more personal in nature. The following case example

reveals how easily boundaries can be violated.

Margaret was a twenty year old college student in her

sophomore year. She was sexually and physically

abused over a ten year period by her stepfather. She

began to have problems managing the stress associ-

ated with her school work. She also began to have

flashbacks and nightmares. One of her instructors

referred her to the school’s counseling center, where

she began to see a professional clinician.

The center has a twelve session limit, and once

Margaret and her counselor reached the limit, Mar-

garet pleaded with the counselor to continue to see

her, since she believed the counselor was the ‘‘only

one’’ who could help her. The counselor agreed to see

Margaret ‘‘on the side’’, for free, in her home. Mar-

garet began to have thoughts of suicide and the

counselor invited her to spend the night with her each

time these thoughts surfaced.

This practitioner’s desire to help Margaret was under-

standable but misguided and ultimately undermined the

client’s self-capacities. The professional’s sense of urgency

could have been constructively channeled into advocating

for a more trauma-informed approach to treatment in her

agency, such as a change in policy regarding session limits

for clients like Margaret. Survivors already struggle with

entering into a therapeutic alliance; therefore, they benefit

greatly from an ongoing, stable relationship with the

clinician.

Instead, the clinician disregarded agency policy, which

ultimately undermined Margaret’s growth. What this

practitioner failed to appreciate was that terminating with

Margaret and referring her to another agency, though

painful, would have provided Margaret with an opportunity

to further develop self-capacities associated with beginning

and ending relationships and managing the difficult feel-

ings associated with these transitions. Unfortunately, the

clinician was significantly impacted by Margaret’s pain

and abandonment issues, suggesting an enactment of

countertransference, discussed later. Inviting Margaret to

stay with her further compromised Margaret’s ability to

manage her feelings on her own. The clinician also left

herself vulnerable to liability issues, because she no longer

was operating under the auspices of her employing orga-

nization. This situation did not end well. The practitioner

was forced to have Margaret hospitalized. Her involvement

with Margaret became known to the school, and she was

fired from her position.

Boundaries between workers and any client population

should remain fluid and open to adjustment, in response to

changing circumstances and contexts (Gabbard 1996;

Lazarus 1994; Reamer 2003). With survivors, the worker

may need to loosen boundaries to be more available in

times of crisis without losing sight of professional role and

responsibilities (Harper 2006). In the previous case, had the

clinician not had to terminate with Margaret, she might

have needed to be more available to the client to deal with

the suicidal thoughts. This doesn’t mean taking Margaret

home. However, it could mean establishing a safety con-

tract that required more frequent meetings with Margaret

and/or keeping in daily contact via phone or email.

In contrast to the last example, this next case illustration

demonstrates how the worker can empathize with a survi-

vor but still set limits and maintain boundaries that promote

empowerment. 1

The worker was a foster care worker and

was providing ongoing case management to Ms. Davies,

who lost custody of her young children after leaving them

1 Adapted from Knight (2009).

Clin Soc Work J (2015) 43:25–37 27

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unsupervised for long periods of time. The worker, Anna,

visited Ms. Davies monthly to assess her progress on her

contract with the agency, the goal of which was re-unifi-

cation with the children. The following exchange took

place as their meeting was ending.

Anna: Well, I guess that’s it for today, Ms. Davies.

You’re doing very well, making a lot of progress. If

things continue on like this, I think you’ll be able to

have [her children] for an overnight visit very soon. Is

there anything else for today?

Ms. Davies: There’s just this one thing. Maybe I

actually already told you this. Did I ever tell you that

when I was a kid, my father pimped me out? He was

a drug addict, like me. He didn’t have no job or

nothing, so he used me to buy his drugs. He’d sell me

to his friends. Let them do what they want to me, and

then take money. Can you believe that? He sold his

own daughter, just to support his drug habit. That

son-of-a-bitch.

Anna: Oh, my, what a terrible story! I had no idea. It

took a lot of courage for you to tell me this. You must

have so many feelings about what your dad did to

you: anger, sadness, confusion. I guess maybe some

of the reason why you were using drugs yourself was

so you didn’t have to feel all this stuff?

Ms. Davies: Yeah, it hurts real bad. It got so, though,

that even when I was using, I would still be thinking

about what he done to me. It’s like I just keep seeing

what happened in my head over and over again.

Anna: I’m sure that this must be so difficult. [Pats

client on the shoulder.] What happened when you

were so little, and then not being able to stop thinking

about it now. You know that my job is to help you do

what it takes for you to get your kids back, right? I

am so glad that you have told me what you did,

because now I can be even more helpful to you. I’m

thinking that the fact that you have shared this with

me means that maybe you are ready to talk about it

with someone. What I’d like to do is refer you to

someone who can help you to do that.

This exchange exemplifies trauma-informed practice in

several ways. Most important, the worker responded

directly to the client’s disclosures of childhood trauma,

conveying her appreciation of the importance of what had

been shared. Anna empathized with Ms. Davies, which in

turn normalized and validated the client’s feelings. Yet,

Anna didn’t lose sight of her role. Anna didn’t offer ser-

vices she couldn’t provide, nor did she delve deeply into

Ms. Davies’s past. Asking Ms. Davies for more informa-

tion about her abuse could have been re-traumatizing and

undermined her self-capacities; it also was inconsistent

with Anna’s role as a foster care worker.

In yet another implication of boundaries, there may be

times when the worker wishes to use physical contact- in

Anna’s case a pat on the shoulder- to provide reassurance

and convey empathy to an adult survivor. Conceivably,

survivors can learn that touch can be soothing and com-

forting, not just harmful and exploitive. Yet, survivors of

childhood trauma need to be empowered to control who

touches them and how, as well as regulate the physical

distance between the clinician and them. Ms. Davies and

Anna had a longstanding relationship, and the client held a

great deal of trust in Anna. In many instances these char-

acteristics will not exist. Thus, the worker typically should

take a conservative approach and avoid using touch as a

therapeutic tool; in those rare instances when it is used, the

worker must adhere to three fundamental principles: The

client must be asked in advance if the worker can touch her

or him, be reassured that she or he can say no, and be

informed what the nature of that touch will be (O’Donohue

and Bowers 2006).

Boundaries should ensure that survivors remain in

control of their bodies. This is especially critical given the

findings of several studies which indicate that survivors of

sexual abuse are at greater risk of being sexually victimized

by therapists than other clients (Nachmani and Somer

2007). Practitioners also must be sensitive to the ways in

which survivors of sexual abuse are prone to sexualize the

relationship they have with the therapist, owing to their

history of having been exploited in intimate relationships

(Nachmani and Somer 2007; Somer and Nachmani 2005).

Practice Considerations

The four-fold principles of trauma-informed practice are:

normalizing and validating clients’ feelings and experi-

ences; assisting them in understanding the past and its

emotional impact; empowering survivors to better manage

their current lives; and helping them understand current

challenges in light of the past victimization (Courtois 2001;

Martsolf and Draucker 2005; Wright et al. 2003).

Practitioners working in settings that address clients’

present-day challenges often feel thwarted in their efforts

to be helpful to survivors because they ‘‘only’’ are able to

assist these individuals with their presenting problems.

However, directly addressing the trauma before the survi-

vor is psychologically and emotionally ready to do so may

serve only to re-traumatize the individual and affirm core

feelings of powerlessness (Classsen et al. 2011; Connor

and Higgins 2008; Harper et al. 2008; Martsolf and

Draucker 2005; Regehr and Alaggia 2006). In contrast,

assisting a survivor in, for example, staying clean, finding

employment, or remaining emotionally stable by taking

necessary medications, is an essential step in addressing

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the long-term effects of the trauma. When the survivor is

better able to manage present-day challenges, her or his

self-capacities are enhanced, and this addresses the past

trauma in a powerful and important way (Glover et al.

2010).

Clinicians working in settings most likely to encounter

survivors of childhood trauma also often assume they lack

the skills necessary to be helpful to survivors. In fact,

strategies that are traditionally used in social work practice

have been found to be effective when working with sur-

vivors. Most fundamentally, the ability to convey empathy

and understanding affirms and validates the survivor’s

feelings and experiences, reducing isolation and feelings of

being alone and different. Cognitive-behavioral strategies

challenge core beliefs and assist survivors in recognizing

and challenging their distortions in thinking; they also

serve to normalize and manage experiences, feelings, and

reactions, and assist survivors in seeing the connection

between present difficulties and the past trauma (Febbraro

2005; Messman-Moore and Resick 2002). Solution-

focused techniques strengthen self-capacities by helping

survivors identify positive ways they have coped in the past

(Knight 2006; Brun and Rapp 2001; Fleming 1998; Tam-

bling 2012). Techniques like writing, art, and other phys-

ical activities allow survivors to express feelings in

alternative, non-verbal ways (Huss et al. 2012; Park and

Blumberg 2002; Pifalo 2009).

More specialized strategies including guided imagery,

hypnosis, and eye movement desensitization and repro-

cessing (EMDR) have been employed with survivors of

childhood trauma. However, these are used most appro-

priately in trauma-centered intervention; they can be

empowering to survivors by helping them learn to relax,

self-soothe, and both express and manage feelings (Bisson

2005; Edmond et al. 2004; Harford 2010; Peace and Porter

2004; Solomon et al. 2009; Struwig and van Breda 2012).

They do require specialized training and an understanding

of the neurophysiological changes in the brain that have

been found to result from childhood trauma (Delima and

Vimpani 2011; Harford 2010). It is critical to note that the

worker should never use any techniques, particularly those

that require this more advanced knowledge, without

appropriate training (Thayer and Lynn 2006; van Minnen

et al. 2010).

Regardless of the techniques to be employed, the clini-

cian should work in partnership with the client, informing

her or him of what strategies the worker intends to utilize

and why (McGregor et al. 2006). The practitioner also

should avoid using any strategy for which there is little or

no evidence of effectiveness or a sound theoretical foun-

dation. While this would seem to go without saying, such

techniques abound in treatment with survivors (Arbuthnott

et al. 2001; Thayer and Lynn 2006). Finally, the worker

must be prepared to help survivors either express or contain

feelings, depending upon what is required to enhance self-

capacities.

In the following example from a 30-day inpatient drug

treatment program, the worker demonstrated her willing-

ness to consider that the client may have a history of

trauma, without jumping to firm conclusions. Notably, she

uses basic skills of social work practice to address the

client’s relatively spontaneous disclosures. The client,

thirty-year-old Rose, was meeting with the intake worker,

Claire, for her initial introduction to the program. After

Claire introduced herself and explained the policies and

treatment options of the inpatient program, she asked Rose

to describe her history of substance abuse. The following

exchange then took place.

Rose: I started using when I was about 10 or 11. I

would sneak into my parents’ liquor cabinet and drink

whatever I could find. I would try to cover it up by

adding water, and I guess it worked, ‘cuz they never

said anything. Of course, they were alcoholics

themselves, and didn’t give a damn about me.

Claire: Wow…that’s pretty young. Sometimes when children use at such a young age it means that they

are trying to escape something. I am wondering if that

might be the case for you?

Silence.

Claire: It appears as if I have struck a chord with you.

I know it can be hard to talk about stuff that happened

in the past, but we can be more helpful to you now if

we know about anything that may have happened to

you when you were little.

Rose: Well, uh, my father would mess around with

me, you know, touch me and stuff.

Claire: I am so sorry to hear this, Rose. This must

have been very difficult for you, very painful.

Rose: (teary-eyed): I have always felt so dirty, so

ashamed about what he did to me… Silence.

Claire: So many of our clients, particularly our

female clients, have had similar experiences. Using

drugs and alcohol becomes a way to escape the pain,

the sadness, the anger, all those feelings that go along

with what your father did to you.

In this brief exchange, Claire normalized and validated

her client’s feelings and experiences through empathy but

did not lose sight of her primary purpose which was to

conduct an initial intake. She allowed Rose to give voice to

what happened to her at the hands of her father, which was

a critical first step towards coming to terms with the vic-

timization. Yet, Claire did not press for a lot of detail or

encourage Rose to engage in in-depth self-disclosure. This

would have been counterproductive and undermined

Clin Soc Work J (2015) 43:25–37 29

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Rose’s self-capacities, particularly her ability to manage

her feelings. It also would have been inconsistent with

Claire’s role as an intake worker.

As Claire sensitively observed, there is a strong corre-

lation between substance abuse and a history of sexual

abuse, particularly for women (Resnick et al. 2013; Ullman

et al. 2013). This enhanced Rose’s feelings of self-efficacy

by helping her better understand her current behavior.

Armed with this information, Rose, Claire, and Claire’s

colleagues could develop a treatment plan that took into

account Rose’s history but also focused on her current

problems with addiction.

In contrast, in this next example, the worker, Joan,

completely ignored the client’s thinly veiled hints about his

history. By doing so, she reinforced feelings of isolation

and deep shame, which are common, particularly among

male survivors (Alaggia and Millington 2008; Clark et al.

2012). The setting was a halfway house for men recently

released from prison. Joan was assigned to work with

Victor throughout his ninety day stay in her program.

Victor had been incarcerated for 10 years for possession of

drugs with the intent to distribute and for breaking and

entering. Joan’s role was to assist Victor in finding housing

and employment once he was released from her program.

The following exchange occurred in their sixth meeting

together.

Joan: So, last week, we were talking about your

introduction to your drug of choice [cocaine]. I

wonder how that was for you that your mother is the

one who encouraged you to use with her?

Victor: Well, at the time, I thought it was cool, you

know? I mean, I was 14, and here I was allowed to

snort coke.

Joan: It must have been confusing for you… Victor (interrupts): Even at the time, when I was a

kid, I guess I knew it was screwed up, that my mom

shouldn’t be using with her kid. But, it was a good

escape from the craziness going on around me.

Joan: So when do you think that it became a problem

for you, when you couldn’t stop anymore?

Victor: From the beginning! The first time I got high,

I was, like, WOW, this feels great! I just numbed

myself out, when all the shit was going down with my

mother’s boyfriends.

Joan: Sounds like a rough time for you, and the coke

provided you with just the escape you needed. Before

you knew it, you were hooked.

On two occasions, Victor offered Joan the opportunity to

inquire about his past. But at neither point did she ask him

for more information. When asked about this, Joan

acknowledged that she picked up on Victor’s hints, but

wasn’t sure what to do with them. She questioned whether

it was ‘‘appropriate’’ for her to ask him about his past,

given the need to help him transition back into the com-

munity. She worried that she would be opening a ‘‘can of

worms’’ if she asked him what he meant by ‘‘the craziness’’

and the ‘‘shit’’ with his mother’s boyfriends. Joan further

conceded that she wasn’t sure what she would do if Victor

were to admit to a history of maltreatment, suggesting that

countertransference also may have been a factor.

With help, Joan came to understand that exploring

Victor’s past in a purposeful way would provide her with

valuable information about what he needed in the present.

In the session that followed, Joan did follow-up on the

comments Victor made previously; he reported that several

of his mother’s boyfriends had sexually and physically

abused him over a five year period. For the remainder of

his stay at her program, Joan assisted Victor in seeing the

connection between his past and present problems. She also

helped him better understand what happened to him when

he was a child, a particularly important strategy since men,

more so than women, are likely to assume their victim-

ization was related to homosexuality (Alaggia and Mil-

lington 2008). She acknowledged and empathized with his

feelings, encouraging him to express what it had been like

for him. Since it often was difficult for Victor to put his

feelings into words, particularly his anger, Joan suggested

alternative strategies, including punching pillows and

working with clay, examples of non-verbal techniques that

have been found to be effective in helping survivors- and

other clients- better manage and control feelings (Baljon

2011; Worthington 2012).

It is empowering for survivors to be able to put into

words their experiences and feelings. But, they also need to

remain in control of their emotions, since this enhances

self-capacities (McGregor et al. 2006; Sweezy 2011).

Further, clinicians need to be mindful of their professional

role and function when encouraging clients to share their

affective reactions. In the previous case involving Rose’s

intake interview, Claire empathized with the client without

encouraging a great deal of self-disclosure, consistent with

the fact that this was a one-session intake interview. In

contrast, once Joan gained an appreciation for how she

could be helpful to Victor during his ninety day stay, she

adopted an interdependent focus on encouraging Victor to

talk about and manage his feelings so they didn’t under-

mine his ability to secure employment and permanent

housing.

Trauma Informed Practice: Challenges

Three particularly noteworthy challenges face clinicians

who work with clients with histories of childhood trauma.

First, there will be instances when the client doesn’t report

30 Clin Soc Work J (2015) 43:25–37

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a history of childhood trauma because of the shame and

embarrassment that such a history engenders; this is

reflected in Victor’s indirect way of addressing his past

victimization. With sensitive, informed questioning like

that conducted by Claire in an earlier example, however,

the worker is likely to elicit relevant information about a

past history of trauma. Directly asking the client about

possible childhood trauma, subtly but powerfully conveys

to the client that she or he can discuss it when ready and

also normalizes and affirms her or his experiences and

feelings.

A related challenge occurs when the client presents with

little or no memory of past trauma. A client’s symptom

cluster and presenting problem(s) may be strongly sug-

gestive of a history of childhood trauma, but don’t provide

conclusive proof. Survivors may not report a history of

childhood trauma because they simply don’t remember it.

One of the ways that these individuals cope with their

victimization is through repression, typically manifested

through memory loss (Ghetti et al. 2006; McNally et al.

2006; Nemeroff 2004). Survivors often have fragmented

and disjointed memories that are confusing to both them-

selves and the worker; this can make assessment and col-

lecting a social history difficult (Legault and Laurence

2007). Thus, the worker may have to tolerate a certain

amount of ambiguity when working with clients who dis-

play difficulties symptomatic of a childhood history of

trauma.

Specialized techniques discussed earlier such as guided

imagery have been used to ‘‘recover’’ (or, according to

some critics, create) memories of abuse, thus generating

much controversy (Alison et al. 2006; Arbuthnott et al.

2001; Thayer and Lynn 2006). The recovered memory

debate centers on the accuracy of memories that surface in

the present regarding abuse that allegedly occurred in the

past. Research supports the existence of such memories but

the findings of other studies call their veracity into question

(Bottoms et al. 2012; McNally 2003; Rubin and Boals

2010). There are documented cases in which memories of

abuse have been manufactured- intentionally or uninten-

tionally- by clients, often with the subtle encouragement of

the clinician (Ashmore and Brown 2010; Fusco and Platania

2011; McNally and Geraerts 2009; Takarangi et al. 2008).

In the following example, the practitioner’s preconceived

notions about what ‘‘must’’ have happened to the client,

Susan, resulted in her asking questions which confirmed

assumptions she- the practitioner- already held. In addition,

the clinician didn’t appreciate the need to assist Susan in

managing her feelings, which ultimately undermined the

client’s self-capacities and increased feelings of self-doubt.

Susan, 35, was being seen in an outpatient mental

health clinic for problems with depression. She

reported few memories of her childhood, but did

recall her parents’ alcoholism and constant fights.

During the course of therapy, Susan reported dis-

turbing memories of her parents’ bedroom and her

father in the bed, naked. The therapist suggested to

Susan that she was sexually abused by her father.

Susan reported later that while she was skeptical of

this, she assumed ‘‘the therapist knew what she was

doing’’. She began to accept that her father ‘‘must

have’’ abused her, even though she never remem-

bered this happening. This resulted in an increase in

her drug use, intensified her feelings of depression,

and led to estrangement from her family and rage.

Once Susan reached the agency’s limits for the

number of sessions she could be seen, she found

another clinician with a great deal of experience and

training working with adult survivors of childhood

trauma. Working together, Susan and her new worker

discovered, through the careful, informed use of

guided imagery, that Susan was not sexually abused

by her father. She recalled that she found her father in

bed, naked, with another woman while her mother

was at work. Her father warned her that she shouldn’t

tell her mother, as it would ‘‘kill’’ her. Further, he

threatened to harm Susan if she told anyone about

what she saw.

The prudent stance in a case such as this is for the

worker to maintain a position of neutrality. The second,

experienced clinician avoided making a priori assumptions

about what Susan’s disjointed memories might mean. After

discussing with Susan in advance what she intended to do,

the practitioner asked the client to describe what she saw

on a movie screen, while in a state of relaxation, a typical

strategy utilized in guided imagery (Leviton and Leviton

2004). The clinician avoided asking leading questions as

well as arriving at conclusions as to what the client’s

descriptions might mean. Working together, Susan and the

practitioner explored the possible meanings associated with

what the client had visualized.

When memories surface in the present and/or are frag-

mented, the worker accepts that memories of abuse may be

psychologically and affectively true, even though they may

not be historically accurate (Reimer 2010; Rubin and Boals

2010). In those instances when the client reports no history

of child maltreatment but presents with many of its

symptoms, the worker remains focused on the present-day

challenges the client faces. The clinician doesn’t ‘‘reach

for’’ memories that she or he assumes ‘‘must’’ be there.

Rather, she or he considers the possibility that there may be

a history of abuse and is prepared to respond should

memories begin to surface, as they often do, on their own

(Bottoms et al. 2012; Rubin and Boals 2010). This is

Clin Soc Work J (2015) 43:25–37 31

123

particularly important in those cases when the client has no

memories at all of her or his childhood, as this has been

found to be a common indicator of childhood victimization

(Crowley 2007; McNally et al. 2006).

The following example underscores yet again the need

for the worker to maintain a neutral stance and avoid

making a priori assumptions about what a client’s memo-

ries might mean. 2

Charles, a client in an inpatient psychiatric facility,

had unclear, fragmented memories of his childhood,

but believed that ‘‘something’’ happened to him in the

basement of his home. He had recollections of being

face down in a pile of laundry and had physical

sensations of being penetrated in his rectum. He also

was able to visualize the shadow of a man standing

over him. Finally, he recalled seeing a tool belt

hanging on the wall in the basement, and believed he

was sodomized with the handle of one of the tools by

his father, who was an abusive alcoholic.

Based upon these recollections, it would be easy for the

practitioner to come to the same conclusions as Charles. In

fact, as Charles talked further about his victimization in

group and individual therapy, his memories of what hap-

pened to him became clearer, a common phenomenon

(Colangelo 2009; Malmo and Laidlaw 2010; Raymaekers

et al. 2012). Charles ultimately was able to see the face of

the person who abused him, and it wasn’t his father. It was

an uncle who had lived with his family, something that he

had not remembered initially. Charles also came to believe

that tools were not inserted in him though he was sodom-

ized. Rather they were in his line of vision, and he focused

on them, so he did not have to think about or feel what was

being done to him by his uncle. This example should serve

as a cautionary tale to all practitioners. The client needs to

be able to tell and make sense of her or his story without

the worker assuming in advance what the story might mean

(Bedard-Gilligan et al. 2012).

A second challenge associated with working with a

client with a history of childhood trauma is related to

mandatory reporting requirements. In many jurisdictions,

mental health professionals must report disclosures from

adult survivors about their abuse as children (Morton and

Oravecz 2009). The worker actually can meet legal

requirements in ways that empower survivors, even though

clients’ initial reactions often include fear of exposure and

vulnerability (Farber et al. 2009). The practitioner should

adhere to three principles. First, the worker must be well-

versed in what her or his legal responsibilities actually are.

Second, the worker should uphold legal mandates in a way

that minimizes risk to survivors. Finally, the worker assists

the client in determining what courses of action to take and

avoids making those decisions for him or her. This, again,

implies that the worker adopt a neutral stance.

In this next example the practitioner handled the client’s

disclosures in a way that undermined his self-capacities

and, ultimately, re-traumatized him. George, the client,

reported the following experience:

When I went to the [outpatient mental health] agency,

they asked me a bunch of questions about my history.

They asked me if I had experienced any type of

sexual abuse. I was embarrassed, man, with them

asking about this shit. But I told them I thought a

neighbor might have fooled around with me when I

was about five or six years old. The person I spoke

with told me that she would need to report what I told

her to the authorities. I begged her not to do it! I

didn’t want anyone to know about what happened,

and I couldn’t really remember much of it anyway,

and now she was going to tell the police?! The guy

still lives next door to my parents! She said that this

was a good thing: that I should file charges against

the guy who molested me. She said I had a right to

get justice for what happened to me. She kept asking

me for more and more detail, and it got me really

upset, particularly since so much of it was really

fuzzy. All I want is to stay healthy!

The practitioner was required by her agency to ask about

possible childhood victimization, due to her state’s

reporting requirements. Therefore, she had to report what

George disclosed to her. What seems like an arbitrary

mandate that will undermine the therapeutic relationship

actually can become a way that the worker and client ini-

tially engage with one another and create a partnership (Oz

and Balshan 2007). What does undermine the working

alliance is when such a mandate comes, from the client’s

viewpoint, out of the blue, as it did for George. In other

words, it’s not the mandate itself that creates the problem,

it’s the way the worker presents it to and handles it with the

client (Morton and Oravecz 2009).

The author’s state is one that requires clinicians to report

an adult client’s disclosures of childhood abuse. The author

tells her clients about the mandatory reporting law at the

outset of the first interview. She and the client then craft a

statement together that satisfies the legal requirement, but

also protects the client, to the extent that is possible. This

strategy actually is empowering for the survivor, despite

the mandated intrusion into her or his privacy.

Another aspect of George’s experience that was coun-

terproductive was the practitioner’s continued questioning;

she really didn’t need additional information to do her job

as a case manager conducting an intake or to fulfill her

state’s mandatory reporting requirements. Collecting2 Adapted from Knight (2009).

32 Clin Soc Work J (2015) 43:25–37

123

detailed information about George’s past was de-stabiliz-

ing and undermined his self-capacities. Further, the clini-

cian’s persistence in encouraging George to take legal

action against his abuser was misguided, particularly given

his disjointed memories of what may have happened to

him. Recovered, fragmented memories are particularly

suspect from a legal perspective (Alison et al. 2006; Binder

and McNeil 2007). It is not up to the worker to decide how

or even whether the client should use the legal system or in

some other way confront abusers or others who may have

been complicit in the victimization (Regehr and Alaggia

2006). The worker’s position should be to provide support,

information, and guidance to the client about available

options but not to tell the client what to do. Given survi-

vors’ core feelings of powerlessness, this is an especially

important consideration.

The worker also should help clients identify what it is

they hope to get out of pursuing legal action or confron-

tation. It is very difficult for adult survivors to prove their

abuse in a court of law, and this is particularly true of

sexual abuse (Alison et al. 2006; Binder and McNeil 2007).

Survivors’ testimony about their recollections of what

happened will be subject to cross-examination. It is not

surprising that all of the author’s clients who have been

through the legal system referred to it as being ‘‘raped all

over again.’’

A final challenge when working with adult survivors

reflects the impact that this has on workers, themselves.

Survivors often present themselves as overwhelmed with

myriad problems and, as discussed, with heightened feel-

ings of mistrust and hostility towards the practitioner

(Bride 2004; Cunningham 2003; Harper et al. 2008; Shafer

and Fisher 2011). Further, their disclosures about what

happened to them, their ‘‘trauma narratives’’ (Etherington

2000), can be extremely hard to hear and their reactions to

the narrative can be hard to witness. Thus, countertrans-

ference is a common reaction among practitioners who

work with survivors (Cramer 2002; Pearlman and Sa-

akvitne 1995). Typical reactions range from disbelief and

avoidance such as that displayed by Joan, Victor’s worker,

to over-identification and rescuing behavior such as that

displayed by Margaret’s worker. While countertransfer-

ence is often assumed to be the result of the worker’s

unresolved issues, in the case of working with survivors, it

is best viewed as a natural consequence of working with

challenging, highly distressed clients (Walker 2004).

Workers also are at risk of being indirectly traumatized

through their work with survivors (Adams et al. 2006;

Knight 2009, 2013; Harr and Moore 2011; Thomas and

Wilson 2004). Three different manifestations of this phe-

nomenon have been distinguished: secondary traumatic

stress, which includes intrusive symptoms comparable to

those that accompany PTSD; vicarious trauma which refers

to the changes in the worker’s views of self and others

analogous to those that occur with survivors; and compas-

sion fatigue in which the worker is unable to generate

feelings of empathy for the client. Indirect trauma is viewed

as an inevitable consequence of working with clients with

histories of childhood trauma over time and witnessing their

pain and distress firsthand (Bride 2004; Baird and Kracen

2006; Jenkins and Baird 2002). Indirect trauma is not the

same as countertransference, which occurs in response to a

particular client (Berzoff and Kita 2010). Yet, each can

reinforce the other (Pearlman and Saakvitne 1995).

It is imperative that workers take steps to minimize the

impact countertransference and indirect trauma have on

them personally and on their work. This includes adopting

self-care strategies that focus on nurturing oneself, estab-

lishing fulfilling relationships, and being pro-active in

managing stress (Bell et al. 2003; Bober and Regehr 2006).

Clinicians need to be vigilant in assessing the impact their

work with survivors has on them. In the following exam-

ple, an intake worker in child protective services described

his reactions to a child client, revealing manifestations of

secondary traumatic stress and countertransference.

Now that I have my own child, I find it a lot harder to

turn off my thoughts about the kids on my caseload. I

just finished up an investigation involving allegations

of physical and sexual abuse of a 4 year-old boy.

Mom was a drug addict and lived pretty much on the

streets. Apparently, she left her son with a series of

boyfriends. The child has signs of having been

repeatedly sodomized. Also a lot of physical injuries.

I have a son who’s five. I look at my son and can’t

help but think of this little boy, and all the other kids

that I’ve seen over the years. My son is happy,

carefree. This little kid, he’s already gone in a lot of

ways. He’s got these dead eyes. I keep seeing those

dead eyes of his every time I look at my son.

I also find myself being so f…ing angry with this boy’s mother. I need to work with her, but I blame

her for her son’s injuries. She doesn’t deserve to have

a child! It’s really hard for me to hide my feelings and

do my job, which is to work toward reunification.

The worker’s honesty in disclosing his feelings and

reaction was the first step towards managing them. His

feelings of anger towards the child’s mother were under-

standable; he is, after all, human. Having a son the same

approximate age as his child client only exacerbated these

feelings. Workers need a place to talk about their feelings.

Thus, agency culture and the supervisory climate should

encourage honest discussion in a way that normalizes,

validates, and helps clinicians manage manifestations of

indirect trauma and countertransference (Brockhouse et al.

2011; Stebnicki 2000).

Clin Soc Work J (2015) 43:25–37 33

123

Conclusion

Adult survivors of childhood trauma are a particularly

challenging group of clients given the long-term effects of

the victimization and the present-day difficulties they face.

In this article, trauma-informed practice is explained,

incorporating the most recent theoretical and empirical

literature. The purpose has been to educate and support

practitioners who encounter survivors of childhood trauma

in settings that are particularly likely to serve these indi-

viduals such as addictions, mental health, forensics/cor-

rections, and child welfare. The practitioner neither ignores

nor dwells exclusively on the trauma. Rather, trauma-

informed practitioners are sensitive to the ways in which

the client’s history affect her or his present-day challenges

and normalize and validate the client’s experiences, con-

sistent with their professional role. Trauma-informed

practice requires the practitioner to understand how the

working alliance, itself, can be used to address the long-

term effects of the client’s childhood trauma. Emphasis is

placed on helping survivors understand how their past

influences the present and on empowering them to manage

their present lives more effectively, using basic skills of

social work practice. Trauma-informed practitioners are, in

fact, well-served by their core training as social workers.

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Dr. Carolyn Knight is a licensed social worker with 30 years of experience working individually and in groups with survivors of

childhood trauma, particularly sexual abuse. She is the author of two

books, numerous articles, and book chapters on working with

survivors of childhood trauma in group and individual treatment.

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